Frequently Asked Questions
How should we view the importance of occlusion today?
Let me say first that I continue to have the greatest respect for the occlusion. However, way too much dentistry is being performed on TMD patients (ortho and restorative) in the name of occlusion—in my opinion.
Very few of us have a perfect bite. Most of us live with some degree of instability in our occlusion without awareness and without symptoms. For me, the key is to get the patient to stop clenching and grinding. I hammer patients on the fact that the only time their teeth should touch is when they swallow. Immediately after a swallow their jaw should relax, and their teeth go slightly apart. If they can do this, they can tolerate a less-than-ideal occlusion, especially if they are wearing a night-appliance. It is the patient who has the “orthopedic instability” of a malocclusion, coupled with parafunctional clenching or bruxism, that becomes symptomatic.
I am also concerned that occlusion is being ignored by too many dentists today. I am seeing a huge increase in thermoplastic devices being made with a suck-down technique. They are being called orthodontic retainers, orthodontic appliances, splints or bleach trays. A thermoplastic suck-down device is just another bad bite. Because they have a uniform thickness, most patients only occlude on the molars of these devices (when the molars are 1 mm apart, the anteriors are 3 mm apart). This can intrude the molars, resulting in the molars being out of occlusion when the device is removed. There is no way the principles of occlusion can be maintained with these devices.
In addition, I continue to be concerned that most dentists seat their fixed prosthodontics out of occlusion. I typically see patients when this has been done to them once too often, and they “loose” their bite. The last dentist to do this is the one who gets blamed, but it was probably the patient’s 4th or 5th crown to be seated in hypo-occlusion. Patients say “My bite was fine until I got this crown,” when the truth is they were an accident waiting to happen because of their previous dentistry. Also be cautious about equilibrating teeth that were not part of the crown-seating procedure. Patients get upset if the dentist has to grind on other teeth because the new restorations were too low.
The key things I look for in the occlusion is bilateral simultaneous posterior contact; vector forces down the long axis of the tooth (no lateral vector forces); anterior guidance; and touching the anterior teeth less than the posterior teeth in a relaxed jaw position. Look for evidence of occlusal trauma, including fremitus, mobility, and hypersensitivity. Look for the signs of clenching, including scalloped tongue, deep overbite, lingual tori, and abfractions. Do not ask patients if they clench or grind. They have no clue--or if they think they do not clench or grind they are wrong. The parafunction of clenching and grinding is a subconscious habit.
What is the accepted ideal condylar position today?
The gnathologists voted for RUM (rear-most, upper-most, mid-most). The lite gnathologists voted for superior, but this was pre-Farrar. The enlightened view today is that there is a physiologic zone in which the condyle can comfortably function. This may be an over-retruded position, as long as the patient is not experiencing capsulitis. Both the kinesiologists and those using electrodiagnostic devices usually end up with the condyle 2-3mm anterior to the seated condylar position. This means they will be recommending phase II dentistry on their patients. However, as I pointed out, this is NOT a stable position long-term, and often results in a dual bite after ortho or restorative.
How many patients need condylar repositioning and/or bite opening?
Very Few!! Look, repositioning a condyle is a big deal. You are committing a patient to thousands of dollars in dentistry they may not otherwise need. In most cases, condylar repositioning is an irreversible procedure, which obligates the patient to extensive dentistry after their jaw is “fixed.” Too often, they are not informed about this contingency at the start of jaw treatment. I get more and more calls from dentists saying something like “I have this patient who seems to have joint capsulitis. Should I build a pull-forward appliance to reduce the joint inflammation?” Condylar repositioning happens in a variety of ways. These include altering the position consciously by evaluating tomographic or CT x-rays, or unconsciously, by relying on devices or techniques such as neuromuscular dentistry or kinesiology to reposition the mandible.
It is generally OK to use a pull-forward appliance for a few weeks to treat a TMJ problem (capsulitis or morning locking), but no longer. However, there are easier and more direct ways to reduce joint capsulitis, including ultrasound, iontophoresis, stopping the cause (clenching and grinding), topical transdermal creams, laser, etc.
As for bite opening, I only recommend it in severely worn dentitions, in which the only way to restore the anteriors is to open the bite. All of the hype generated about “proper vertical for optimum muscle function and comfort” is the propaganda of neuromuscular dentistry. The big lie works if it is repeated loudly enough and long enough, again and again. It sells a lot of electronic boxes to a lot of dentists who want to do a lot of dentistry. Once they have invested thousands of dollars in these devices, they will find the patient to fit their pet diagnosis.
How many of your patients need phase II dentistry?
See above section for the answer to this question. Short answer: less than 10%.
What is the best type of splint?
It depends on the diagnosis. First of all, all splints should fit passively and be stable without rocking, and without eliciting lateral vector forces on the teeth (otherwise, you have an orthodontic appliance, not a splint). A suck-down appliance is not a splint—it is another bad bite. Soft splints have been shown by EMG sleep studies to actually induce greater muscle activity than baseline. Any splint should incorporate the principles of occlusion: stable posterior contact, anterior guidance, no posterior tooth contact in eccentric movements (immediate posterior disclusion). These principles apply regardless of the type of splint it is. Maxillary splints are easier to adjust, cause less tooth movement, and are generally the only type that can be a deprogrammer. I don’t worry about appearance or altered speech with an upper splint, because I do not have the patient wear them more than 2-3 hours during the day, in 15 min intervals (if they can’t control daytime clenching). I use deprogrammers in clenchers IF they have a deep overbite (more than 50%). Deprogrammers (in which they only occlude on the lower centrals) are much more effective in reducing elevator muscle activity. I then convert the same appliance to a stabilization splint within a few weeks.
How long should patients wear splints?
The only time I have a patient wear a splint full-time is after TMJ surgery or arthrocentesis (joint lavage) for 2 to 6 weeks. I will occasionally make two splints for a patient (one upper, one lower), if they are experiencing daytime locking. There are significant risks in asking a patient to wear a splint full-time. There is a much greater chance the patient will have altered muscle length, permanent changes in muscle engrams, or a psychological dependence on the splint. All of this makes it much harder to wean the patient off the splint. The fact that they do worse when they stop full-time splint wear is not evidence that they need this vertical dimension of occlusion to be comfortable. Full-time wearing of a splint dramatically increases the likelihood that the splint will move the teeth, including intrusion, super-eruption, or lateral movement. I am OK with patients wearing splints indefinitely, as long as it is during sleeping hours only, and as long as it stays in adjustment.
I agree with Gordon Christensen when he says 1/3 of all patients should wear a splint during sleeping hours. Splints are not just for TMJ patients. Patients sometimes get upset when I point out that they have worn through the enamel on many of their teeth. They ask me “Why didn’t my dentist tell me about this?”
What are your “most common” diagnoses?
If I only looked for the most common, I would be assured of missing the less common. For me, the rewarding challenge of the TMD patient is the diagnostic hunt. We can only diagnose what we know. Here is the list of the 150 I try to keep in my brain. This is not an exhaustive list. I wrote it in about an hour. I see the first 40 of these every week. I have seen all of these in my practice. Obviously, some of them had to be confirmed by other clinicians.
This list includes contributing factors, as well as formal diagnoses.
- Masticatory myalgia
- Lateral pterygoid
- Medial Pterygoid
- Cervical myofascial pain
- Levator scapuli
- C-1 or styloid or coronoid tendonitis
- Internal derangement
- Closed lock
- Parafunctional clenching
- Muscle bracing / splinting
- Local muscle soreness
- Muscle hypertrophy
- Genetically weak ligaments
- Trauma-induced ligament damage
- Poor sleep hygiene
- Tension-type headache
- Sensory Perception Disorder
- Parafunctional sleep posture (stomach-sleeping)
- Degenerative joint disease
- Erosion of condylar head
- Intra-condylar bone cysts
- Loss of cortical bone
- Osteophytes (bone spurs)
- Torn/perforated bilaminar ligament
- Idiopathic resorption of condyle
- Distalizing contacts
- Striking anterior teeth prematurely
- Lateral slide
- Severe class II’s (greater than 3 mm overjet)
- Collapsed bite
- Unilateral posterior open bite
- Anterior open bite
- Non-working interferences
- “Division I” (retro-inclined upper anterior teeth)
- Locked in occlusion
- Occipital neuralgia
- Traumatic arthropathy
- Chronic pain patient
- Subluxation locking
- Joint effusion
- Occlusal trauma
- Migraine w/o aura (common migraine)
- SSRI / SNRI –induced nocturnal bruxism
- Postural distress
- Neuropathic pain
- Neurogenic inflammation
- Coronoid tendonitis
- Tongue thrust
- Abscessed tooth referring pain to jaw
- Fibrous adhesions
- Post-surgical condylar resorption
- Hyperemesis-induced permanent ligament damage
- Maxillary sinus mucosal disease
- Migraine w/ aura (classic migraine)
- Rebound analgesic headache (medication overuse headache)
- Transformed migraine
- Developmental deformities
- Mandibular asymmetry (often due to childhood trauma)
- Lingual tori
- Scalloped tongue
- Obstructive sleep apnea
- Sexual abuse
- Physical abuse, by spouse, boyfriend, or parent
- Otitis media (confirmed by ENT)
- Hemifacial hyperplasia
- Temporal arteritis
- Chiari Malformation
- Cluster headache
- Acute paroxysmal hemicrania
- Trigeminal neuralgia
- Complex region pain syndrome (formerly called reflex sympathetic dystrophy)
- Sympathetically-maintained pain
- Nerve root impingement (cervical)
- Frontal sinusitis
- Sphenoid sinusits
- Muscle trismus secondary to needle trauma
- Muscle atrophy
- Muscle spasm (rare)
- Acute occlusal awareness
- Bipolar disorder
- Borderline personality disorder
- Somatiform disorder
- Secondary gain
- Chronic Fatigue Syndrome
- Ehlers-Danlos Syndrome
- Sjogrens Syndrome
- Rheumatoid Arthritis
- Oromandibular Dyskinesia / dystonia
- Tardive Dyskinesia, often secondary to phenothiazines
- Accutane-induced myalgia/myofascial pain
- Ankylosis, both fibrous and boney
- Post-herpetic neuralgia
- Trigeminal neuropathy
- Drug dependency
- Munchausen’s (including “by proxy”)
- Blocked parotid duct
- Parotid tumor
- Apical breathing
- Burning mouth/tongue syndrome
- Capsular fibrosis
- COPD-induced jaw pain
- PFO-induced migraine
- Eagle syndrome
- Extension-flexion arthropathy (whiplash)
- Glossopharyngeal neuralgia
- Psoriatic arthritis
- Coronoid impingement
- Calcified stylohyoid ligament
- Stylomandibular tendonitis
- Mandibular nerve trauma/neuropathy
- Steroid-induced necrosis (TMJ)
- Osteochondritis dessicans
What are the typical treatment choices to consider after examining a patient?
There are over 50 types of treatment recommendations I use over the course of a year. Some recommendations include referrals to other clinicians. It can’t emphasize enough that no treatment options should be considered without thoroughly evaluating the patient, and deciding what the various etiologies are for that patient (see the 3 Contributing Factor Categories, Chapter 1). The treatment has to be tailored to the contributing factors/etiology. As stated above, the typical patient is given 4-7 recommendations. The more challenging may get up to 10 recommendations. Some of the recommendations made to patients include the following:
- Jaw Instructions in avoidance of harmful habits
- Splint (deprogrammer, stabilization, pull-forward, pivot, Tanner, etc)
- P.T. referral, with script including diagnosis, all contributing factors, exacerbating factors, parafunction, treatment goals, precautions, treatment frequency, and treatment length. Only P.T.’s with advanced training and experience will consistently help TMD patients. There is now a TMD/Orofacial Pain certification available for P.T.’s
- Jaw school
- TMJ Healing Plan, by Cynthia Peterson, P.T.
- TMD CD for progressive relaxation of masticatory muscles
- Glucosamine, Omega 3 fatty acids, Vitamin D, Calcium, Magnesium (for patients with bone loss). See handout.
- NSAID, either OTC or script, typically Lodine, 400 mg bid prn pain
- Muscle relaxant, typically cyclobenzaprine, 2 ½ - 5 mg, 10 hours prior to wakeup time (typically 8pm)
- Instructions regarding restrictions at work, singing, or contact sports to avoid
- Therapeutic exercises
- Laser treatment (class 3b gallium cold laser)
- Topical transdermal cream (may contain pregabalin, Ketamine, ketoprophen, gabapentin, lidocaine, amitriptyline, others)
- Flector Patch (diclofenac)
- Trigger point injection (rarely needed with good P.T. and laser)
- Unlock joint, either in-office or under I.V. sedation by oral surgeon
- Neurologist for migraine assessment, Chiari malformation, neuralgia, RSD, or sensory perception disorder (SPD)
- Chronic pain therapist (primarily for self-hypnosis to block the pain or for severe clenchers)
- Counselor for stress management
- Blood test for 17β-estradiol and Vitamin D (for patients with bone loss)
- Inject Coronoid ligament (with Celestone) for temporal tendonitis
- Speech pathologist, for tongue thrust
- Consult with PCP, to substitute for SSRI meds (Prozac, Paxil, Zoloft, Celexa, etc)
- Primary care physician, for physical, blood screen, hyper/hypotension, thyroid
- Oral surgeon, for unlocking under i.v. sedation, arthrocentesis (lavage), arthrotomy, Botox, biopsy, clip lingual frenum, or orthognathic surgery
- Gabapentin, with instructions for titrating drug plus guidelines and warnings. Given for trigeminal neuralgia, neuropathic pain, acute capsulitis, migraine preventive, trigeminal nerve trauma, herpes zoster or severe nocturnal bruxism
- Follow-up CT, to check DJD progress or evaluate airway in sleep appliance
- Mounted study models, using facebow and semi-adjustable articulator
- Occlusal adjustment, to reduce grossly high teeth due to DJD or surgery, or for fine-tuning after active jaw treatment.
- Pulse oxymetry over-night study, plus review of study and consult w/ pt
- Amitriptyline or nortriptyline, used to augment gabapentin in neuropathic pain
- Klonopin, given for no more than 2 weeks, hs
- Anterior jig (not NTI), rarely made, used to evaluate if pt would benefit from a splint, not worn more than two weeks, hs.
- Orthodontist, besides std ortho, sometimes for a condylar repositioning device, i.e., Herbst, Jasper Jumpers, or Forcus springs, primarily in young patients
- Referral to Fibromyalgia / chronic fatigue syndrome specialist
- General dentist for restorative work to address malocclusion, after resolution of symptoms
- Prosthodontist, after resolution of symptoms
- Neuro-otologist, to r/o acoustic neuroma, vestibular neuropathy
- Sleep physician
- Sleep appliance
- Chronic pain clinic
- Movement disorder clinic, UofU, for orofacial Dyskinesia, mandibular ataxia
Notes: For the typical TMD patient, they are referred to 1 or 2 other clinicians. None of the above drugs used are prescribed long-term. I write less than 6 narcotic analgesic scripts per year. Surgery is recommended to less that 3% of our patients. P.T. is recommended to 70%.